CDC may recommend circumcisions

When Teresa Cho and her husband, Jay, found out they were expecting a baby boy, they faced a dilemma they hadn't considered before: whether to circumcise him.

The Chandler couple went back and forth on the issue, right up until Wednesday, the day little Edward was born.

Ultimately, they decided against it.

Choosing not to circumcise is a decision more and more parents are making these days.

Since peaking in the 1960s at about 80 to 85 percent, the percentage of infant boys being circumcised has steadily declined, standing at about 56 percent today.

But that trend could soon reverse course again.

For the first time, the U.S. Centers for Disease Control and Prevention and the American Academy of Pediatrics are considering whether to recommend the surgery as a preventive measure against HIV transmission. Both groups have had a neutral stance on the issue and neither has advocated for it.

Their recent and ongoing discussions have been prompted by three large studies in sub-Saharan Africa that showed that circumcising healthy heterosexual men cut their HIV-transmission rate in half.

"Right now, our folks are considering all the information and what might be appropriate, given the best available science," said Jennifer Horvath, a CDC spokeswoman. She added that the agency is looking primarily at recommendations for three groups: infant males, adult heterosexual men and gay men. Most adult men in the U.S. are circumcised.

The CDC's announcement is expected sometime this summer, while the academy has not given a timetable for its decision.

Although any recommendation would still ultimately leave the decision in the hands of parents, the potential for new guidelines is worrying anti-circumcision groups, who liken the procedure to genital mutilation and say any health benefits are negligible or unproven.

Cultural history

Circumcision, the clamping and subsequent removal of the foreskin that covers and surrounds the tip of the penis, has historically been performed primarily for religious or cultural reasons. Parents also were influenced by some evidence suggesting it offered health and hygiene benefits.

The procedure is typically done by obstetricians or pediatricians shortly after an infant is born, and it usually takes 15 to 30 minutes. Complications are rare.

Doctors and other public-health experts cite various reasons for the downward trend in circumcision over the past four decades, including an influx of residents from Latin America and other countries where the surgery is not routine.

Another major factor: In the past decade, 16 state Medicaid programs, including Arizona's, have dropped coverage for circumcision. More than half of the state's babies, 52 percent, are now born on the Arizona Health Care Cost Containment System, the state's Medicaid program.

Arizona dropped coverage of circumcision in 2002.

Although exact numbers are hard to come by, data from the Arizona Department of Health Services suggests that the number of baby boys being circumcised has been 20 to 24 percent over the past four years. The exact percentage is unknown because the data includes only procedures performed in the hospital and does not capture infants circumcised through Indian Health Services, in pediatrician offices or during traditional religious ceremonies, such as a bris. That occurs on a Jewish infant's eighth day of life.

The data, however, is similar to conclusions reached in a January 2009 study by the University of California-Los Angeles.

In addition, circumcision rates vary widely across the country, the study found. Among the regions, Western states have the lowest rates in general, at about 27 percent.

Arleen Leibowitz, a professor of public policy at UCLA's School of Public Affairs and the lead researcher on the study, said she hopes that any change in the CDC's guidelines would prompt Medicaid programs like AHCCCS to again pay the cost of the surgery.

Health benefits

Leibowitz and other proponents say there is growing evidence that circumcision has health benefits.

These include reducing an infant's risk of getting a urinary-tract infection and an adult man's chances of developing penile cancer or becoming infected with a range of sexually transmitted diseases, including herpes, syphilis and the human papillomavirus.

She fears that if current trends continue, it will lead to increasing health disparities among the poor and minority populations, who have higher rates of sexually transmitted diseases. She likens circumcision to vaccinations, which are covered by Medicaid.

"The policies we have today are going to have long-term effects," she said. "We should be giving parents who are on Medicaid the option (to circumcise). They have the same right as richer parents to choose something that could be good for their baby."

The CDC says the African studies provide some of the most compelling evidence yet that circumcision can reduce the risk of sexually transmitted diseases. Researchers found that heterosexual men in Kenya, Uganda and South Africa who were circumcised were about half as likely to become infected with HIV.

It appears that the foreskin provides a damp environment that makes it easier for viruses to invade and grow, researchers said.

Critics such as Georganne Chapin, founder of the anti-circumcision advocacy group Intact America, argue the African studies shouldn't apply to the U.S. because transmission here is most common among homosexual men.

Circumcision has not been shown to have any impact on transmission rates of HIV among men who have sex with men, according to a 2009 CDC study.

As for the other benefits, Chapin said that an infant's risk of developing a urinary-tract infection is relatively rare, as is the likelihood of developing penile cancer. Diseases, she said, can easily be prevented with responsible use of condoms.

Dr. Philip Gleason, a pediatric urologist who practices in the Valley, agrees that circumcision isn't medically necessary for most infants.

But he believes the potential long-term benefits still outweigh the perceived negatives.

'A safe procedure'

"I think a lot of people in the medical field say, 'I am going to be a little more proactive and take the preventive approach, as opposed to the wait-and-see approach,' " said Gleason, who performs two to three circumcisions a week. "It's a very safe procedure."

For parents like Teresa and Jay Cho, it came down to personal choice.

They heard and listened to arguments on both sides, including from members of their own family, who advocated for circumcision for cultural and hygienic reasons.

"My parents are still kind of like, 'We think you should do it,' " Teresa said. "But I think it should be up to (our son). If he wants to do it later, then it's up to him. It'll be his decision."